Case Study 1

Group 9: Pumpkins

Nutrition Care

Progress Note

ASSESSMENT

DIAGNOSIS

INTERVENTION

MONITORING & EVALUATION

31 y.o F w/ gravida 3, para 2

Dxs of: Hypochromic
Microcytic Anemia; 23 week
gestation with normal
ultrasound

Inadequate energy intake (NI1.2-10634) R/T nausea during

the first trimester of pregnancy
and limited food preferences
AEB pregnancy weight gain
that is 7# or 50% short of the
recommended weight gain
(14#) for patients prepregnancy BMI and length of
gestation.

Energy-modified diet (ND 1.2.210830) to increase caloric intake

and increase pregnancy weight
gain to a healthy level.

Monitor for weight gain (AD1.1.4)

Meds: Prenatal vitamins;

ferrous sulfate
Skin: Pale, warm and dry
Eyes: Sclera pale
Lab values (abnormal):
RBC - 3.8 x 10 /mm
Hgb - 9.1 g/dL3
MCV - 72 m
TIBC - 465 g/dL
Ferritin - 10 g/dL
Folate 2 ng/dL
Hct - 33%
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Wt: 142# (64.5 kg)

UBW: 135# (61.4 kg)
Ht: 55
IBW: 125#
BMI: 22.5, normal

Diet: NPO
(only while admitted).
Appetite: Self-reported as

Inadequate mineral intake

(iron) (NI-5.10.1-10712) R/T
increased nutrient needs
during pregnancy AEB 19.4 mg
of iron intake according to 24hour-recall (PTA) relative to the
RDA of 27 mg for pregnant
women as well as a low
plasma ferritin level of 10
ug/dL, a low hemoglobin level
of 9.1 g/dL, and an increased
TIBC value of 465 ug/dL.

DATE & TIME:

Continue taking iron supplements

(ND - 3.2.4 10541) and prenatal
vitamins. Advise pt to take
supplements with food to increase
tolerance and minimize GI upset.
Take iron supplements alongside
foods high in vitamin C to maximize
absorption.
Provide nutrition education r/t
increased nutritional needs during
pregnancy and relationship of
nutrition to maternal and fetal
health/disease (E 1.4-10591).

10/14/2014 08:00

Monitor her calorie intake (FH1.1.1.1)

Monitor lab values where
available, particularly plasma
ferritin, transferrin, Hgb, TIBC,
MCV, iron, folate, and vitamin C
(BD-1.10; BD-1.13)
Monitor tolerance of and
adherence to taking iron
supplements and prenatal
vitamins, including associated GI
distress.

Provide nutrition education,

specifically skills to select iron-rich
foods (E 2.2-10597).
Referral to community
agencies/programs (WIC) (RC 1.610625).
Vitamin-modified diet (ND 1.2.910837) to increase vitamin C and
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Case Study 1
good, but does not like many
foods; 24-hour recall of dietary
intake PTA indicated PO
intake of 1,752 kcal, protein
intake of 46.6 g, iron intake of
19.4 mg, and folate intake of
733 g DFE.

Group 9: Pumpkins
folate consumption.
Mineral-modified diet (ND 1.2.1010838) to increase iron intake so
that she can be weaned off of the
iron supplement.

EEN: 2,025 kcal/day

(HBEx1.2 activity factor+350
kcal for 2nd pregnancy)
67.5 g protein/day
(61.36 kg x 1.1 g/kg/day)
Fluids: 2,000-2,400 mL/day
(specific calculation: 64.545
kg x 35 mL/kg = 2,259 mL)

Signature & Credential: Alainna Baxley, Kelsey Conyers, Xiaolu Hou, and Sarah Liu, (future) RDs

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